For FAXCHECK: Print this page, affix filled-out check, fax in.
For E-mail check: Highlight and copy this form into an E-mail. Fill in & Send.
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FAX/E-mail Check Payment - Draft Authorization Agreement
RareBird Consulting Services Tel: 707-527-7785
400 West Third St. #D-243 FAX: 707-542-5587
Santa Rosa, Ca. 95401 E-Mail to info@rarebird.net
To Be Completed by Payer
Name _______________________________________________
Date ______________________________
Signature(s) __________________________________________________
I (we) hereby authorize and request RareBird Consulting Services to withdraw
amounts owing by me (us), for the order(s) which I (we) placed and transmitted
and /or for any amounts that become due, as indicated on payment check(s)
affixed below from my (our) bank or financial institution account(s) named on the
check(s), and I (we) authorize and request my (our) bank(s) or financial institution(s)
named below to accept debit entries initiated by RareBird Consulting Services to
such account(s) and to debit the same to such account(s) without responsibility
for the correctness.
Bank or Financial Institution __________________________________________________
Address __________________________________________________
City ___________________________ State________ Zip __________
ABA Number (expressed as a fraction on upper right side of check) _____________________
Check Number _____________
Bank Routing Number :_________________: Account Number _________________
For FAX check, affix the payment check with the top of the check covering this line of text.
Fax this form to FAX number above, later mark your check VOID and keep for your records.
For E-mail Check, send filled-out check, signed, but with VOID written across check, to
address above after you submit this e-mail authorization. We will prepare a draft document
and debit your account. Be sure not to use that check number for any other transaction.
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